Henning JS, Wohltmann W, Hivnor C. Teledermatology From a Combat Zone. Arch Dermatol. 2010;146(6):676-677. doi:10.1001/archdermatol.2010.110
Historically, dermatologic conditions account for between 15% and 75% of all outpatient visits in the combat environment during wartime.1 Teledermatology has proven to be an effective adjunct to extend dermatologic services to remote locations.2,3 Since July 2004, the US Army has operated a store-and-forward teledermatology consult service for deployed medical providers. This service is responsible for a substantial number of consults and enhances the care of deployed service members worldwide. Herein, we outline the uniqueness of this program and evaluate the cost savings.
We reviewed store-and-forward teledermatology consults that military health care providers generated between January 2005 and January 2009 while deployed with the US Army. Deployed health care providers who needed a dermatology consult took digital photographs and e-mailed them along with a brief history to a single e-mail address at a monitored server. The e-mails were then distributed to the on-call consulting dermatologists. More than 40 military dermatologists answered the consults on a rotating basis in a “team call” approach. The percentage of total consults and diagnostic agreement between primary care provider and dermatologist were calculated. In addition, the number of other comments by the call team was determined.
For the cost calculation, intertheater transfer of a patient to be evaluated by a dermatologist in Iraq was estimated to be $4000, while the cost of evacuation to the United States was estimated to be $14 082 (including the cost of lost duty days, ground transportation, airlift via helicopters and other aircraft, extra personnel required for security and transportation crews, and housing of patients during their evaluation and treatment).4
A total of 2197 consults generated between January 2005 and January 2009 were reviewed. The most prevalent diagnoses by the consultant dermatologists were eczema (13%, n = 285), fungal infection (7%, n = 153), and bacterial infection (7%, n = 152). There was a 34.4% diagnostic agreement between the provisional diagnosis of the primary health care provider and the teledermatology consultant. The most common diagnoses that the referring health care providers were able to correctly identify were smallpox vaccination reactions (59%) and leishmaniasis (75%). In total, 75.3% of the consults could be answered with a single definitive diagnosis by the dermatologist (n = 1655), and 24.7% of the consults were answered with a differential diagnosis (n = 542). Additional comments were provided in 18% of the single definitive diagnosis group (n = 297) and 73% of the differential diagnosis group (n = 395). A total of 1.4% of the consults recommended evacuation back to the United States (n = 40), for an estimated cost of $562 380; 4.7% of patients were referred for in-person evaluation by the dermatologist in Iraq (n = 104) for a cost of approximately $416000.
Historically, primary health care providers provide most of the dermatologic care in a wartime environment.1 Dermatologists in the military remain in short supply. Because of the high demand and low availability of dermatologists, teledermatology is an excellent specialist extender that allows primary health care providers worldwide access to dermatology consults.3
Currently, dermatology accounts for 31% of all telemedicine consults initiated by the US Army's telemedicine consult service.5 One of the unique features of this program is that all of the dermatologists on the call team see the original question and response. Once the consult has been answered, the other members of the team are free to reply to the on-call dermatologist with additional thoughts. The original consultant then compiles the secondary comments and forwards these to the originating provider. This allows for an “instant quality control” aspect to this system. More additional comments were received when the on-call dermatologist replied with a differential diagnosis than when the reply specified a single definitive diagnosis.
A total of 2157 patients could be managed in Iraq, which is an overall cost savings of approximately 30.4 million dollars. One additional benefit of teledermatology in the combat setting is the incalculable savings of avoiding the risk of travel in a war zone.
This study demonstrates the role and cost savings of teledermatology in the combat setting. Dermatologic conditions remain a common complaint among deployed soldiers, and teledermatology can substantially reduce the number of patients who need to be evacuated for treatment, resulting in substantial cost savings.
Correspondence: Dr Henning, 59 MDOS/SG05D/Dermatology, 2200 Bergquist Dr, Ste 1, Lackland AFB, TX 78236-9908 (firstname.lastname@example.org).
Accepted for Publication: January 14, 2010.
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Henning and Wohltmann. Acquisition of data: Henning. Analysis and interpretation of data: Henning, Wohltmann, and Hivnor. Drafting of the manuscript: Henning and Wohltmann. Critical revision of the manuscript for important intellectual content: Henning, Wohltmann, and Hivnor. Statistical analysis: Henning and Wohltmann. Administrative, technical, and material support: Henning, Wohltmann, and Hivnor. Study supervision: Henning, Wohltmann, and Hivnor.
Financial Disclosure: None reported.